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HomeMy WebLinkAbout034-1025-30-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No:` v GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1) AJA- Permit Holder's Name City Village ownship Parcel Tax No: I CST BM Elev: Insp. B ev: BM Description: Section/Town/Range/Map No. ll. i9. t5, r f( TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM V0 Aeration Bldg. Sewer 14 ct Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration 1rCc 4 1 Dist. Pipe Holding Bot. System PUMP/SIPHON INFORMATION Final Grade Manufacturer D GPM emand St Cover f Z L Ga 7 Model Number `-7~ 3 TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size X Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of Teeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes E No Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:: Location: 1314 6e_./~ / 1.) Alt BM Description al~/Pi'/ 2.) Bldg sewer length - amount of cover = 1 - nn 7'f~Z/ o i1 ~C. Plan revision Required? ❑ Yes ENO Use other side for additional information. L L477 t(/ Date Insepcto' Signatur Cert. No. SBD-6710 (R.3/97) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 582009 Personal information you provide maybe used for secondary purposes [Privacy Law, x.15.04 (1)(m)]. 2613335 Permit Holders Name: City Village Township Parcel Tax No: St. Croix County Glen Hills County Pad TOWN OF SPRINGFIELD 034-1025-30-000 CST BM Elev: Insp. BM Elev: BM Description: SectiowTown/Range/Map No: 160 / 11.29.15.171 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER 1% CAPACITY STATION BS ~HI FS ELEV. 6 Septic , ti 1%40% 17-06/160 Benchmark A A yt <<i ZZ- 6 / Dosing 5er P / SG5 Alt. t LA, • t Bldg. Sewer V2 90 •CI Holding ~ ~ SUHt Inlet /0. 755 ,Z TANK SETBACK INFORMATION St/Ht outlet 18.5 90 TANK TO P/L MWELLBLD5G. Air IntakeROAD Dt Inlet //-Z smr Septic Dt Bottom Sc4` Dosing 7 g / Header/Man. tt, 9S Aeration Dist. Pipe f.cye. '741r 6-5 Holding Bot. System PUMP/SIPHON INFORMATION Final Grade dis . G•S Manufacturer Zoe e ) Demand st Cover 9s^a r 'T 77~• Model Number di0 / 9G ~6 J Z V 9.3 TDH Lift Friction L 4-43 oss System Hea -0-65 TDH I ` ~t • ( f Forcemain Lang t / Dla.I / Dist to well 761 SOIL ABSORPTION SYSTEM BEDITRENCH Width / Length I No. Of Trenc PIT DIMENSIONS No. Of Pita inside Dia. Liquid Depth DIMENSIONS /O GO sL e - ~ SETBACK SYSTEM TO D fr.7P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer. INFORMATION Type ystem. / CHAMBER OR 71t0 ' ` /a5 ~ ~OO UNIT Model Number: DISTRIBUTION SYSTEM 7~ Header/Manifdd ID istribution x Hole Size I x Hde Spacing Ve v Aike PlpLength T Dla J'S Length Dia-18 Spacing 71+ Z~ SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only - 4 lot Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center 45 Bed/Trench Edges Topsoil J f ` ' A% Yes ® No Yes ® No COMMENTS: (include code discrepancies, persons present, etc.) Inspection t«1: / O f x 7/6 1Inspection #2: Location: No Address Av ills / ~ ; 1.) Alt BM Description = ` ire-erg r~aaJ 2.) Bldg sewer length = J 1 SA -amount of cover 6 C4&L 0^ Cka f^W.% PA.$j ta~ej A/ AIL Plan revision Required? Jul Yes WNo Use other side for additional information. 1 1 V SBD-6710 (R.3/97) Date Insepctor's Si lure Cerl No. L- MAY 2 ~ i County 3anitar r(d~~i pkati uN7 ~ArlS ~ii~,i3 ' I accord oil h Chapart ".2 S.. (.r01X -ounty Sanlla-r} Ordinance s~ ~r'>iEi~+.~ u: rva`~j b ➢4.j L NV ~p Mnai in'io,,nation you provide may be used fo- secondary purpos es ~O ~~K11f~ P~ ~ENT~ - . [Privacy Lang. S 15.04(1)(r1,j ~r 3 h Road a I 6J7 10 7, Fa "71 151386-4686 Attach complete plans for the system on paper not less than 8-1/2 lit • ir:. s County Sanitary Permit # ❑ Check if revision to previous appllc u~, -m. t. Application I:nforma.ion - Please Print all information 1 , n, ok ; Property Owner Name ~ 4 114, sec > R E (or) iN Property Owner's Mailing Address' o' f•lu .ber Block Number 3 p~p.. 5 City, State Zip Code Phone Numer i; ub division Nanne or CSM Number G< ~11 Type of BuildNu (chec one} U _ ro;' ( 311 , (i own o` 1 ~ ^r 2 i a -,il f No, i;f Bedroo,-,;s: } ~D Public/Commercial (describe use): D State-owned j je r t i r no Type of Perrmt ((Check only one box on {ine A. Check box on line B if applicable} _ sic-' J Tax plumber(s) 1.C3 Repair 2JQ Reconnection 3.0f4on-plumbing 4. El Rejuvenation A) Sanitation. ~ B) Permit Number late, lssued State Sanitary Permit was previously issued K, T7 of Poybrr System: (Check all that apply) ❑ Non-pressurized In-ground ❑ Mound z 24 in. suitable soil M Mourx3 2,' in s~ itshl soil ❑ Mound A+0 t ❑ Sand Filter ❑ Constructed Wetland L] Peat Fairer Drip Line ❑ Pressurized In-around © Holding Tank E] Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit D Recirculatinc V. Dispersal/Tre-atment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation, RFtF. 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sgA.). (Min.'inch) jj Elevation "Vt. Tana Information Capaicty it Gallons Total # of Manufacturer Pre`ak, . i,T' Con-, Fiber- ~ Plastic New Existing Gallons Tanks Concrate stiucted glass Tanks Tanksa L(t~ _ ❑ ❑ ❑ 0 "Vii, Resparesibility Statement (L the undersigned, assume responsibility for rep it/re -nn /rejuv ation/installation of non-plumbing for the POW`i"S shovvn on the attached plans. A ~tlicense is not required for terralif; repair or the in allati r of !um sanitation ystem. )Plumber's Narne rent) Plumber's Sign ati n st mp M~ ji PP° t oo. 'i w ss Phone Number Plumber's Address (Street, City, State, Zip Code) 6 6g- NAIIN 1`- Vill. County Use Only Disapproved Sanitary Permit Fee Date ! sued !sslllnq Agent Signature (No stamps) Approved Owner Given Initial Adverse rx.r~ Determination emu... IX. Conditions of Approval/Reasons for Disapproval: Rev: 8/05 a) C-~. 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